Journal Article Annotations
2017, 2nd Quarter

HIV Psychiatry

Annotations by John Grimaldi MD and Mary Ann Cohen MD, FAPM
July 2017

Association of implementation of a universal testing and treatment intervention with HIV diagnosis, receipt of antiretroviral therapy, and viral suppression in East Africa

Also of interest:

Tiberghien P, Pillonel J, Toujas F, Vallet B: Changes in France’s deferral of blood donation by men who have sex with men
N Engl J Med 2017; 376(15):1485-1486

This letter to the editor describes France’s deferral policy for blood donation by men who have sex with men (MSM) and ongoing epidemiologic surveillance that may pave the way for a deferral policy similar to other risk exposures. France’s 2016 policy decision changed blood donation by MSM from permanent to 12-month deferrals. However, it stipulated no sexual contact within 12 months of donation in contrast to other risk exposures which allowed sexual contact with no more than one person. The rationale given for this difference was the lack of evidence for donor adherence to guidelines and HIV incidence among MSM with no more than one sexual partner. Quarantining of samples of donated plasma and retesting of donors 2 months after initial donation enables detection of HIV in blood donated within the window period between transmission and a positive HIV antibody result. Thus, blood donation for plasma apheresis carries the same conditions for MSM as for other donors: donors who had no more than one partner over the previous 4 months. The authors conclude that “such a donation offers a unique opportunity to safely assess the epidemiologic features of HIV among MSM donors who are subjected to identical deferral rules as other donors.”
Cohen MA, Gorman JM, Jacobson JM, Volberding P, Letendre SL (Eds): Comprehensive Textbook of AIDS Psychiatry: A Paradigm for Psychosomatic Medicine, 2nd Edition
New York, Oxford University Press, 2017

Published in May 2017, this second edition is the first book to provide updated insight into the interface between the psychiatric, medical, and social dimensions of HIV and AIDS and the need for a compassionate, integrated approach to the HIV pandemic with an emphasis on humanizing and destigmatizing HIV.

Dr. Mary Ann Cohen, lead editor of the textbook, is a psychosomatic medicine, addiction, geriatric, and HIV psychiatrist; chair and founder of the APM HIV/AIDS Psychiatry SIG; and president and co-founder of the World Psychiatric Association Section on HIV/AIDS Psychiatry. Dr. Cohen assembled an integrated group of co-editors, including: Drs. Jack M. Gorman, research psychiatrist; Jeffrey M. Jacobson, HIV vaccine researcher and infectious disease specialist; Paul Volberding, global AIDS specialist and medical oncologist; and Scott L. Letendre, neuroAIDS specialist and infectious disease specialist. The book is based on the integrated clinical, academic, administrative, research experience, and expertise of the editors and contributors in the fields of global HIV, infectious disease, HIV psychiatry, vaccine development, and neuroAIDS throughout the course of the HIV pandemic from 1981 to the present.

Drawing from the expertise of 135 contributors in clinical and evidence-based medicine, the book provides information on the prevalence, incidence, medical, and psychiatric aspects of HIV, as well as on the prevention and care of persons with HIV/AIDS. A majority of contributors are members of the WPA Section on HIV/AIDS Psychiatry and the APM HIV/AIDS SIG. Every member of the American Psychiatric Association Office of HIV Psychiatry contributed one or more chapters. Specialists, clinicians and researchers in every field of medicine and psychiatry and experts in HIV epidemiology, ethics, neuropathology, an AIDS orphan, neuropsychology, psychology, health care policy, advocacy, social work, nursing, epidemiology, vaccines, prevention, and women’s health contributed chapters.
- This is the only comprehensive textbook of HIV psychiatry that includes chapters on HIV advocacy, prevention, women’s issues, the association of trauma, PTSD and nonadherence in HIV, models of collaborative care for persons with HIV, medical multimorbidities, HIV vaccines, HIV/HCV co-infection, and HIV education and training.
- It is the only book to address the complex connections between psychiatric disorders and HIV transmission, treatment of psychiatric manifestations of HIV, the social context of anti-HIV discrimination in which HIV psychiatry is practiced, and specific psychiatric modalities of HIV treatment.
- The book is meant to humanize HIV and addresses HIV stigma and discrimination throughout.
- All potentially stigmatizing words such as “these” patients or “such” patients have been removed.
- The section on the comprehensive assessment pays explicit attention to the human aspects of the illness and to the need for caring for persons with HIV with dignity, respect, and compassion.
- The emphasis is on compassionate, non-judgmental communication and care.
- The chapter on AIDS orphans is written by an AIDS orphan as lead author and by specialists in the epidemiology of AIDS orphans.
- The chapter on HIV advocacy is written by AIDS advocates.
- The book presents a section on HIV through the life cycle from childhood to older age.
- The book has a chapter on HIV and correctional facilities.
- Some unique aspects of this textbook are: the chapter on medical aspects of HIV is written by expert clinicians and researchers in infectious disease and HIV, the chapter on integrative treatments is written by experts in the field of integrative care, the chapter on HIV and HCV coinfection is written by experts in hepatology and in HIV psychiatry, as are the other chapters of the section on multimorbid medical illness in HIV.
- The book covers the important aspects of HIV prevention as well as the dynamics of nonadherence to HIV care and addresses ways to improve adherence through integrated care.
- There is a section on treatment that includes chapters on psychotherapy, integrative therapies, palliative therapy, and psychopharmacologic treatments.
- There is a special chapter on burnout that takes into account the impact of technology and productivity as drivers of physician burnout in all specialties and provides ways to address it in the care of persons with HIV.
- The book includes a resource guide for persons with HIV and AIDS, their families and caregivers, and clinicians, educators, and researchers.

PUBLICATION #1 — HIV Psychiatry

Association of implementation of a universal testing and treatment intervention with HIV diagnosis, receipt of antiretroviral therapy, and viral suppression in East Africa

Petersen M, Balzer L, Kwarsiima D, et al

JAMA 2017; 317(21):2196-2206

Importance: Antiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set global targets to diagnose 90% of HIV-positive individuals, treat 90% of diagnosed individuals with ART, and suppress viral replication among 90% of treated individuals, for a population-level target of 73% of all HIV-positive persons with HIV viral suppression.

Objective: To describe changes in the proportions of HIV-positive individuals with HIV viral suppression, HIV-positive individuals who had received a diagnosis, diagnosed individuals treated with ART, and treated individuals with HIV viral suppression, following implementation of a community-based testing and treatment program in rural East Africa.

Design, Setting, and Participants: Observational analysis based on interim data from 16 rural Kenyan (n = 6) and Ugandan (n = 10) intervention communities in the SEARCH Study, an ongoing cluster randomized trial. Community residents who were 15 years or older (N = 77 774) were followed up for 2 years (2013-2014 to 2015-2016). HIV serostatus and plasma HIV RNA level were measured annually at multidisease health campaigns followed by home-based testing for nonattendees. All HIV-positive individuals were offered ART using a streamlined delivery model designed to reduce structural barriers, improve patient-clinician relationships, and enhance patient knowledge and attitudes about HIV.

Main Outcomes and Measures: Primary outcome was viral suppression (plasma HIV RNA<500 copies/mL) among all HIV-positive individuals, assessed at baseline and after 1 and 2 years. Secondary outcomes included HIV diagnosis, ART among previously diagnosed individuals, and viral suppression among those who had initiated ART.

Results: Among 77 774 residents (male, 45.3%; age 15-24 years, 35.1%), baseline HIV prevalence was 10.3% (7108 of 69 283 residents). The proportion of HIV-positive individuals with HIV viral suppression at baseline was 44.7% (95% CI, 43.5%-45.9%; 3464 of 7745 residents) and after 2 years of intervention was 80.2% (95% CI, 79.1%-81.2%; 5666 of 7068 residents), an increase of 35.5 percentage points (95% CI, 34.4-36.6). After 2 years, 95.9% of HIV-positive individuals had been previously diagnosed (95% CI, 95.3%-96.5%; 6780 of 7068 residents); 93.4% of those previously diagnosed had received ART (95% CI, 92.8%-94.0%; 6334 of 6780 residents); and 89.5% of those treated had achieved HIV viral suppression (95% CI, 88.6%-90.3%; 5666 of 6334 residents).

Conclusions and Relevance: Among individuals with HIV in rural Kenya and Uganda, implementation of community-based testing and treatment was associated with an increased proportion of HIV-positive adults who achieved viral suppression, along with increased HIV diagnosis and initiation of antiretroviral therapy. In these communities, the UNAIDS population-level viral suppression target was exceeded within 2 years after program implementation.

On PubMed: JAMA 2017; 317(21):2196-2206

Annotation

The finding: The Sustainable East Africa Research in Community Health Study (SEARCH) is an ongoing randomized trial comparing an innovative HIV test-and-treat strategy in rural Kenya and Uganda against country-specific standard of care for HIV on outcomes. Using observational data from SEARCH, this study reports interim results of proportions of HIV-positive individuals in the test-and-treat intervention who had received a diagnosis, individuals treated with antiretroviral treatment (ART), and treated individuals with HIV viral suppression at baseline and after 1 and 2 years. Compared to baseline, the rate of population-level viral suppression after 2 years, the primary outcome, rose from 44.7% to 80.2%, representing an increase of 35.5%. After 2 years, secondary outcomes were as follows: the rate of HIV-positive individuals who had been previously diagnosed was 95.9%; HIV-positive individuals who had received ART was 93.4%; and individuals who had been treated who had achieved HIV viral suppression was 89.5%. At both baseline as well as at 2 years, viral suppression was lower for males than for females and lowest for youth (aged 15-24 years). This study demonstrated that “WHO guidelines to treat individuals regardless of CD4 count can be successfully implemented.” In addition, an innovative test-and-treat strategy in rural East Africa was successful in achieving the UNAIDS 90-90-90 goal of 73% viral suppression in a relatively short time.

Strength and weaknesses: The study comprised a large number of individuals, 77,774 adults enrolled at baseline, a high proportion of women, and geographic areas that are currently far below UNAIDS 90-90-90 targets. The intervention was multi-faceted and included innovative testing strategies and streamlined engagement and treatment techniques. Given the observational nature of the analysis, the intervention effect on the positive outcome cannot be determined until the trial has been completed. The primary analyses included individuals who remained in the target communities for the full duration of the study period. These residents may represent a relatively easy group to reach and therefore do not account for other populations more likely to negatively impact treatment as prevention goals. The study does not provide insight about how to reach, engage and retain in care migrants in and out of the community. The study also is not designed to evaluate the impact of a successful test-and-treat outcome on population level HIV incidence.

Relevance: The study findings are highly relevant across all geographic areas, from developed to those with limited resources. Sweden is the only country to have achieved 90-90-90 cascade goals and there are significant questions about whether the same can be achieved in rural areas with a higher disease burden. For example, in the US only 40% of individuals diagnosed with HIV are retained in care and only 30% achieve viral suppression. HIV prevalence is highest in the Southeastern US where a higher proportion lives in rural areas. The outreach and treatment strategies offer important insights about scalable ideas applicable to all settings. The model was patient-centered with an emphasis on reducing structural barriers, improving patient education, enhancing clinician-patient relationships and adapting services to reflect patient preferences and expectations. For example, testing occurred at community health fairs offering multidisease screening to reduce stigma and entry into care was immediate and occurred at point of testing. Additionally, the study highlighted the need for improved models for testing, linkage to and retention in care for youth and males.